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ffaarba- C`�o �t+ ?��eneral STINGO! UNDFRGROUxD 7ANKSATAFFORDABLE RATES'UALITYTEQ j5 Office Box 36 Thornton, Ca 95686 (209) 797�4-71112;L .'E11EALTH DEPARTt'lENT Information Bldg.No.: Facility Name: City: gyp' Site Address: Contact Phone No.: Facility Contact Person: c00 i /"� Date of Testing/Servicing: Make/Model of Monitoring System: h C/9 h 1 > B. Inventory of Equipment Tested/Certified fTankID a ro riate boxes to indicatespecific equipment inspected/serviced: hD/U Vii h PQM Tank ID: ng U ❑ In-Tank Gauging Probe. Model: nk Gauging Probe. Model: ❑ Annular Space or Vaul[Sensor. Model: lar Space or Vault Sensor. Model: Ll piping Sump/Trench Sensor(s). Model: g Sump/Trench Sensor(s). Model: -- Fill Sump Sensor(s). Model: ump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: anical Line Leak Detector. Model: 13Electronic Line Leak Detector. Model: onic Line Leak Detector. Model: Tank Overfill/High-Level Sensor. Model: ❑ Tank overfill/High-Level Sensor. Model: O Other(s ui ment and model in Section E on Page 2). 13 Other(s eci a ui ment and model in Section Eon Pa a 2). /.� a r,� Tank ID: � A Z At Q o $7 Tank ID: Model: ❑ In-Tank Gauging Probe. Model: L3 In-Tank Gauging Probe. p Annular Space or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Model: ❑ piping Sump/Trench Sensor(s). Model: ❑ Piping Sump/Trench Sensor(s). Model: U Fill Sump Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: ❑ Mechanical Line Leak Detector. Model: ❑ Mechanical Line Leak Detector. Model: a Electronic Line Leak Detector. Model- ❑ Electronic Line Leak Detector. Model: El Tank Overfill/High-Level Sensor. Model: El Tank Overfill/High-Level Sensor. Model: ❑ Other(specify equipment a and model in Section E on Pae 2). ❑ Other(specify a ui ment eand model in Section E on Pae 2). / Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ Shear Valve(s). - ❑ Dis enser Containment Float(s)and Chain(s). ElDispenser Containment Float(s)and Chain(s). L i! _ Dispenser : Dispenser ID: In: Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: ❑ Shear Valve(s). ❑ ShearValve(s). ❑ Dis Denser Containment Float(s)and Chain(s). ❑ Disperser Containment Flost(s)and Chain(s). Dispenser ID: '/ I �- Dispenser ID: qaA Q-Dispenser Containment Sensor(s). Model:1-11 `j J3 Dispenser Containment Sensor(s). Model�K(Jbr � J El Shear Valve(s). &Shear Valve(s). ❑ Dispenser,Containment Float(s)and Chain(s). Dis enser Containment Float(s)and Chain(s). *If the facility contains more tanks or dispensers,copy this form Include information for every tank and dispenser at the facility. C. Certification-I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoringO i stem setup y equipment❑Alarm historof y report ting such reports,I have also attached a copy of the report;(check aR that apply): Y ` imp Technician Name(print): Signature: - �---- jTl il3 Certification No.: d 410 Co 36 h 0 License.No.: " C19 I I CG tp 52 iA'i`%5 - u i Monitoring System Certification 4 1 1#